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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200670
Report Date: 10/20/2023
Date Signed: 10/20/2023 10:09:26 AM


Document Has Been Signed on 10/20/2023 10:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:ACAPULCO SENIOR CARE HOMEFACILITY NUMBER:
019200670
ADMINISTRATOR:KA, NINFACILITY TYPE:
740
ADDRESS:14160 ACAPULCO ROADTELEPHONE:
(510) 924-7457
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:6CENSUS: 0DATE:
10/20/2023
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Joyce Galera-Rodriguez and Aurora EbidoTIME COMPLETED:
10:15 AM
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On 10/20/2023 at 09:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived announced to inspect the facility prior to closure. Upon arrival, the LPA identified himself and verified the purpose of the meeting with former Administrator Joyce Galera-Rodriguez and former Caregiver Aurora Ebido.

The LPA verified that there are no residents currently living at the facility. LPA verified that there are also no resident or staff or facility records at the facility.

Exit interview conducted and a copy of this report was provided via email to the Aurora Ebido.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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